Case Presentation on: Nasopharyngeal Carcinoma presenting as Multiple Cranial Nerves Involvement

1. Case presentation on:
Presented by:
Dr.SAHAR.J.HADI
ENT Center- Sulaimanyia Teaching Hospital- Sulaimanyia- Iraq
Nasopharyngeal Carcinoma
presenting as
Multiple Cranial Nerves
Involvement

2. Case Report
A 60 years old man presented with history of pain over left side
of face and diplopia for two months.
 A week later he developed drooping of left eyelid and
simultaneously difficulty in swallowing both liquids and solids,
associated with nasal regurgitation of food ,nasal speech and
left ear tinnitus.
 These complaints worsened progressively over two months
and at the time of presentation he could not open his left eye.
 There was no history of weakness of any other part of body,
ataxia, or loss of sensation over body.
 Bladder and bowel habits were normal. There was no history of
fever, epistaxis, swellings in neck, hemoptysis, or weight loss.

3.  Past medical.
medical history is insignificant other than newly diagnosed diabetes mellitus.
 Past surgical
no previous ear or nose surgery. No trauma
Social history
he has smoked half a pack per day for almost 30 years and admits to drinking one or
two beers daily .no same condition in the family member

4. Examination
 General examination :- conscious ,alert ,oriented to time and place.
Pale ,no jundice,no obvious lymphadenopathy. Vitally is stable
 Ear examination. Conductive deafness was
present on the left side.
 Oral examination:-Uvula was deviated to right side; gag reflex was
absent on left side, tongue was atrophied on left side and on tongue
protrusion it deviated to left .

5.  Neck examination. Normal apart of One jugular-digastric lymph node (2
cm × 3 cm) was palpable on left side of the neck. It was hard in
consistency, and not fixed to underlying structures, or skin.
 Ocular examination:-There was complete ptosis and no ocular
movements were possible on left side. Diplopia was present on all
gazes. Pupils were bilaterally equal and reacting normally to light .
There was decreased sensation on left side of the face and consensual
corneal reflex was absent.
 Cranial nerve examination:- III,IV,V,VI,IX,X,XI,XII
 There was weakness in left sternocleidomastoid muscle. There was
no sign of cerebellar dysfunction or meningeal irritation.
• Nasal examination:- by anterior rhinoscopy was normal ,0 rigid
endoscope of left nasal cavity reveal mass occuping the left fossa of
rosen muller,obstructing the left ET but not obstruct the posterior chonea

7. Management
 CT-scan of head done for the patient ,showed a soft tissue density
mass of 4.86 x 4.55 cm size in left nasopharyngeal area extending into
the right side of nasopharynx . On separate sections, the growth was
seen extending into the cavernous sinus area , sphenoid sinus, and left
temporal lobe.

8. Managment
 Fine needle aspiration cytology from the left jugulodigastric lymph
node suggested a secondary carcinoma.
 Biopsy was taken by posterior rhinoscopy under GA from the
suspicion mass and sent for H/P ,was suggestive of non-
keratinizing un differentiated nasopharyngeal carcinoma.
 RX:- The patient was diagnosed as stage 4 T4N1M0 nasopharyngeal
carcinoma with involvement of cranial nerves III, IV, V, VI, IX, X, XI, XII on
the left side with metastasis to ipsilateral jugulodigastric lymph node. He
was treated with combination chemotherapy with 5-fluorouracil and
cisplatinum along with external beam radiotherapy.

9. NASOPHARYNGEAL CARCINOMA
Background:-
 Nasopharyngeal carcinoma (NPC) is unique in its epidemiologic
pattern. It is common in certain ethnic groups.
 The majority of patients with NPC are diagnosed with advanced
disease.
 The strategy in the management of NPC is to find novel methods of
early detection and to develop improved techniques of effective
primary treatment, with the focus on reducing morbidity from the
treatment.

10. Epidemiology
¾ of patient with NPC are males.3:1 M/F.
 Common in southern China , Hong Kong , and Singapore.
 Affected early aged group (15-35),(50-60).
 The incidence decrease with age.
 10% of cases with dermomyositis have a risk for NPC.

11. ETIOLOGY
GENETIC
FACTORE
VIRAL FACTORS
ENVIROMENTAL
FACTORS

12. Histologic Classification of
Nasopharyngeal Carcinoma(WHO)
Differentiated non keratinize
carcinoma
Undifferentiated non
keratinize carcinoma
Keratinizing squamous cell
carcinoma
Basaloid squamous cell
carcinoma

13. PRESENTATION
PRESENTATION
60% PALPAPLE NECK
MASS
41% BLOOD STAINED
DISCHRGE
30% CONDUCTIVE
HEARING LOSS
LESS 10% PERSISTANCE
HEADACHE OR CRANIAL
NERVE PULSIES

14. DIAGNOSIS
FULL ENT HX+EX
IMAGING
BIOPSY
SEROLOGY
AUDIOLOGICAL+OTHER

15. NASOENDOSCOPY
EXOPHYTIC
MASS
ULCERATIVE
MASS
INFLITRITIVE
OR
SUBMUCOSL

16. IMAGING
IMAGING
MRI
U/S
PET/
CT
C/T

17. C/T MRI
IMAGING

18. IMAGING
 PET/CT

19. STAGING
 Stage Description T Classification
TX Primary tumor unable to be assessed
T0 No evidence of tumor
T1 Confined to nasopharynx or extends to
oropharynx and/or nasal cavity.
 T2 Tumor extends to parapharyngeal space
.
T3 erosion of skull base , cervical vertebra
ptergoid plate+/- PNS
T4 Tumor involves sinuses and/or skull
base Intracranial , infratemporal, masticator
space involvement, cranial nerve involvement,
orbit, or hypopharynx.

20.  N Classification
N0 No nodal involvement .
N1 Unilateral cervical lymph nodes ≤6 cm, or
unilateral or bilateral retropharyngeal nodes ≤6
cm, above supraclavicular fossa .
N2 Bilateral cervical lymph nodes ≤6 cm,
above supraclavicular fossa
N3a Lymph node >6 cm .
N3b Supraclavicular lymph node

21.  M Classification
 M0 No distant metastasis.
 M1 Distant metastasis (includes mediastinal
nodes) .
 Stage Classification
Stage I T1N0M0 .
Stage II T1N1M0, T2N0M0, T2N1M0.
 Stage III T3N0M0, T3N1M0, T1 to T3N2M0
 Stage IVa T4, any NM0 .
Stage IVb Any TN3M0 .
Stage IVc Any T, any N, M1

22. Spreading
NASAL
CAVITY+PNS
CLIVUS+
VERTEBRE
HYPOPHARYNX
PARAPHARYNAL
SPACE

23. Treatment
treatment
Primary
tumor
Radiotherapy Chemotherapy
Recurrent
locoregional
Local
recurrent
tumor
Regional
recurrence

24. Treatment
RECUREENT
LOCOREGIONAL
TUMOR
LOCAL
RECURREN
T TUMOR
2nd course
of
radiotherapy
Salvage
surgery
RECURRENT
REGIONAL
TUMOR
RND
RND+
radiotherapy

25. Treatment
 Surgical salvage :-
A- endoscopic approach through extended transnasal anterior skull
base surgery
 Advantages:
1-simple technique.
2- direct approach .
3- excellent visualization of the operating field.
4-Two surgeon – four-hands technique.
 Limitations and drawbacks:
1- limited access to the lateral infratemporal.
and parapharyngeal space.
2-difficult assessment of the margin.
status in malignant Disease.
3- limited data of reconstruction outcomes.
4- Dural reconstruction challenging.
5-Risk of meningitis due to wound contamination.

26. Treatment
 B- open approach that includes the following:-
INFERIOR
APPROARCH
• TRANSPALATL
APPROACH
Anterior
approach
• Mid facial
degloving
approach
ANTERIO-
LATERAL
APPROCH
• MAXILLAY
SWING
APPROAH

27. Treatment
ANTERIOLATERAL
APPROACH • FACIAL
TRANSLOCATION
APPROACH
Lateral approach
• Lateral
skull base
approach

28. Follow up
 After 12 weeks post radiotherapy frequent nasoendoscpe
and biopsy should be done for the patient.
 Long-term follow-up of all patients is essential. Most failures
occurs within 2 years of treatment.
 Regular 2–3-monthly follow-up in the first 2 years, increased
to 3–4 times per year in the third to fifth years, followed by 6-
monthly or yearly reviews is advisable.